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1 1 Provider Number (Medicare/VHI) PIC X(6) 1 6 Medicare Provider Number or number assigned by VHI. 2 Provider NPI PIC X(10) 7 16 Provider's NPI 56 3 Patient Control Number PIC X(20) Patient Control Number on UB-04 3a 4 Discharge Date PIC 9(8) Discharge/Statement Covers Period Through Date in MMDDYYYY 6 format 5 Patient Zip Code PIC X(9) Zip Code of Patient Address 9d 6 Patient Date of Birth PIC 9(8) Date in MMDDYYYY format 10 7 Patient Sex PIC X(1) M, F or U 11 8 Admission Date PIC 9(8) Date in MMDDYYYY format 12 9 Admission Hour PIC 9(2) Hour of admission in military time (00-23) Admission Type PIC X(1) See UB-04 manual for valid codes Admission Source PIC X(1) Source of Referral for Admission or Point of Origin for Admission - 15 See UB-04 manual for valid codes. 12 Patient Status PIC 9(2) Patient Discharge Status - See UB-04 manual for valid codes Medical Record Number PIC X(17) Medical Record Number on UB-04 3b 14 Revenue Center Code 1 PIC 9(4) As specified for UB Revenue Center Units 1 PIC S(7) As specified for UB Revenue Center Charges 1 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 2 PIC 9(4) As specified for UB Revenue Center Units 2 PIC S(7) As specified for UB Revenue Center Charges 2 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 3 PIC 9(4) As specified for UB Revenue Center Units 3 PIC S(7) As specified for UB Revenue Center Charges 3 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 4 PIC 9(4) As specified for UB Revenue Center Units 4 PIC S(7) As specified for UB Revenue Center Charges 4 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 5 PIC 9(4) As specified for UB Revenue Center Units 5 PIC S(7) As specified for UB Revenue Center Charges 5 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 6 PIC 9(4) As specified for UB Revenue Center Units 6 PIC S(7) As specified for UB C) Signed Fields (PIC S) - Same as Numeric Field except Signed if negative (-) Page 1
2 31 Revenue Center Charges 6 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 7 PIC 9(4) As specified for UB Revenue Center Units 7 PIC S(7) As specified for UB Revenue Center Charges 7 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 8 PIC 9(4) As specified for UB Revenue Center Units 8 PIC S(7) As specified for UB Revenue Center Charges 8 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 9 PIC 9(4) As specified for UB Revenue Center Units 9 PIC S(7) As specified for UB Revenue Center Charges 9 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 10 PIC 9(4) As specified for UB Revenue Center Units 10 PIC S(7) As specified for UB Revenue Center Charges 10 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 11 PIC 9(4) As specified for UB Revenue Center Units 11 PIC S(7) As specified for UB Revenue Center Charges 11 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 12 PIC 9(4) As specified for UB Revenue Center Units 12 PIC S(7) As specified for UB Revenue Center Charges 12 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 13 PIC 9(4) As specified for UB Revenue Center Units 13 PIC S(7) As specified for UB Revenue Center Charges 13 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 14 PIC 9(4) As specified for UB Revenue Center Units 14 PIC S(7) As specified for UB Revenue Center Charges 14 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 15 PIC 9(4) As specified for UB Revenue Center Units 15 PIC S(7) As specified for UB Revenue Center Charges 15 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 16 PIC 9(4) As specified for UB Revenue Center Units 16 PIC S(7) As specified for UB Revenue Center Charges 16 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 17 PIC 9(4) As specified for UB C) Signed Fields (PIC S) - Same as Numeric Field except Signed if negative (-) Page 2
3 63 Revenue Center Units 17 PIC S(7) As specified for UB Revenue Center Charges 17 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 18 PIC 9(4) As specified for UB Revenue Center Units 18 PIC S(7) As specified for UB Revenue Center Charges 18 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 19 PIC 9(4) As specified for UB Revenue Center Units 19 PIC S(7) As specified for UB Revenue Center Charges 19 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 20 PIC 9(4) As specified for UB Revenue Center Units 20 PIC S(7) As specified for UB Revenue Center Charges 20 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 21 PIC 9(4) As specified for UB Revenue Center Units 21 PIC S(7) As specified for UB Revenue Center Charges 21 PIC S(8) V Dollars and cents with an implied decimal Revenue Center Code 22 PIC 9(4) As specified for UB Revenue Center Units 22 PIC S(7) As specified for UB Revenue Center Charges 22 PIC S(8) V Dollars and cents with an implied decimal Total Charges PIC S(8) V Dollars and cents with an implied decimal; if greater than $999,999.99, then use Payer Identifier A PIC X(25) Enter the Board of Health approved payer designation which will be the nationally assigned PAYERID, it's successor, or English description of the payer. 82 Payer Code A PIC X(2) For VHHA only 83 Payer Identifier B PIC X(25) Enter the Board of Health approved payer designation which will be the nationally assigned PAYERID, it's successor, or English description of the payer. 84 Payer Code B PIC X(2) For VHHA only 85 Payer Identifier C PIC X(25) Enter the Board of Health approved payer designation which will be the nationally assigned PAYERID, it's successor, or English description of the payer. 86 Payer Code C Pic X(2) For VHHA only 87 Patient Relationship to Insured A PIC X(2) See UB-04 manual for valid codes. 59 A A per 50 B per 50 C per C) Signed Fields (PIC S) - Same as Numeric Field except Signed if negative (-) Page 3
4 88 Patient Identifier (SSN) PIC X(9) Enter the nine-digit social security number of the patient. If a social security number has not been assigned, leave blank. The ninedigit social security number is not required for patients under four years of age. 89 Employment Status Code PIC X(1) Employed Full Time; 2-Employed Part Time; 3-Not Employed; 4- Self-employed; 5-Retired; 6-On Active Military Duty; 9-Unknown See 90 Employer Identifier PIC X(24) Enter the federally approved EIN, or employer name, whichever is adopted by the Board of Health. 91 Principal Diagnosis Code PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 92 Other Diagnosis Code 1 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 93 Other Diagnosis Code 2 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 94 Other Diagnosis Code 3 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 95 Other Diagnosis Code 4 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 96 Other Diagnosis Code 5 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 97 Other Diagnosis Code 6 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 98 Other Diagnosis Code 7 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 99 Other Diagnosis Code 8 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 100 Other Diagnosis Code 9 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 65 A with name/codes noted in A 67-B 67-C 67-D 67-E 67-F 67-G 67-H 67-I C) Signed Fields (PIC S) - Same as Numeric Field except Signed if negative (-) Page 4
5 Item 101 Other Diagnosis Code 10 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 67-J 102 Other Diagnosis Code 11 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 67-K 103 Other Diagnosis Code 12 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 67-L 104 Other Diagnosis Code 13 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 67-M 105 Other Diagnosis Code 14 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 67-N 106 Other Diagnosis Code 15 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 67-O 107 Other Diagnosis Code 16 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 67-P 108 Other Diagnosis Code 17 PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 67-Q 109 Admitting Diagnosis Code PIC X(7) Codes set ICD-9 or their successors, omit decimal External Cause of Injury (ECI) Code PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 72-a 1 (ECODE1) 111 External Cause of Injury (ECI) Code PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 72-b 2 (ECODE2) 112 External Cause of Injury (ECI) Code PIC X(8) Codes set ICD-9 or their successors, omit decimal; eighth 72-c 3 (ECODE3) 113 Principal Procedure Code PIC X(7) Codes set ICD-9 or their successors, omit decimal Principal Procedure Date PIC 9(6) Date in MMDDYY format Other Procedure Code A PIC X(7) Codes set ICD-9 or their successors, omit decimal 74-a 116 Other Procedure Date A PIC 9(6) Date in MMDDYY format 74-a 117 Other Procedure Code B PIC X(7) Codes set ICD-9 or their successors, omit decimal 74-b 118 Other Procedure Date B PIC 9(6) Date in MMDDYY format 74-b 119 Other Procedure Code C PIC X(7) Codes set ICD-9 or their successors, omit decimal 74-c 120 Other Procedure Date C PIC 9(6) Date in MMDDYY format 74-c 121 Other Procedure Code D PIC X(7) Codes set ICD-9 or their successors, omit decimal 74-d C) Signed Fields (PIC S) - Same as Numeric Field except Signed if negative (-) Page 5
6 122 Other Procedure Date D PIC 9(6) Date in MMDDYY format 74-d 123 Other Procedure Code E PIC X(7) Codes set ICD-9 or their successors, omit decimal 74-e 124 Other Procedure Date E PIC 9(6) Date in MMDDYY format 74-e 125 Attending Physician PIC X(10) NPI or UPIN based on effective dates as specified by CMS Operating Physician PIC X(10) NPI or UPIN based on effective dates as specified by CMS Other Physician/Provider 1 PIC X(10) NPI or UPIN based on effective dates as specified by CMS Other Physician/Provider 2 PIC X(10) NPI or UPIN based on effective dates as specified by CMS Infant Birth Weight (in grams). PIC 9(4) Required by VHI. Required for infants only , Value Code Patient Race PIC 9(1) Patient Race. Required by VHI. Use the following codes: 0 = White; 1 = Black; 2 = Other, specified; 3 = Asian; 4 = American Indian; 5 = Hispanic - White; 6 = Hispanic - Black; 9 = Unknown, not recorded 131 Patient Street Address Pic X(40) Patient Street Address is a required field. Enter the valid patient's residence street number and street name. Do not include PO Box numbers. 132 Patient City or County Pic X(30) Patient City or County is a required field. Enter the valid patient's complete City or County of residence. 9a 9b C) Signed Fields (PIC S) - Same as Numeric Field except Signed if negative (-) Page 6
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